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A 27-year-old female client is admitted to the psychiatric hospital with a diagnosis of bipolar disorder, manic phase. She is demanding and active. Which intervention should the nurse include in this client's plan of care?
- A. Schedule noncompetitive activities that can be carried out alone.
- B. Monitor her decision-making process.
- C. Encourage her to identify feelings of anger.
- D. Provide a structured environment with little stimuli.
Correct Answer: D
Rationale: Clients in the manic phase of bipolar disorder require a structured environment with decreased stimuli to help manage their symptoms. Providing a structured environment with little stimuli (D) can help reduce the risk of escalating behaviors. Scheduling noncompetitive activities that can be carried out alone (A) is more appropriate than group activities as excessive stimuli should be avoided. Monitoring decision-making processes (B) is important due to impulsivity in manic phases. Encouraging the client to identify feelings of anger (C) is not the priority in managing manic symptoms, as it is more often associated with depression than bipolar disorder.
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A male client is admitted to the psychiatric unit for recurrent negative symptoms of chronic schizophrenia and medication adjustment of risperidone (Risperdal). When the client walks to the nurse's station in a laterally contracted position, he states that something has made his body contort into a monster. What action should the nurse take?
- A. Medicate the client with the prescribed antipsychotic thioridazine (Mellaril).
- B. Offer the client a prescribed physical therapy hot pack for muscle spasms.
- C. Direct the client to occupational therapy to distract him from somatic complaints.
- D. Administer the prescribed anticholinergic benztropine (Cogentin) for dystonia.
Correct Answer: D
Rationale: The correct action for the nurse to take in this situation is to administer the prescribed anticholinergic benztropine (Cogentin) for dystonia. Dystonia can be a side effect of antipsychotic medications like risperidone, leading to involuntary muscle contractions and abnormal postures. Benztropine is an anticholinergic medication commonly used to treat dystonia. Choices A, B, and C are incorrect because thioridazine is not the appropriate medication in this case, a hot pack would not address the underlying issue of dystonia, and occupational therapy is not the primary intervention for addressing acute dystonic reactions.
A male client with schizophrenia tells the nurse that the FBI is monitoring his phone calls. What is the nurse's best response?
- A. Let's talk about your feelings of being monitored.
- B. There is no evidence that the FBI is monitoring your calls.
- C. Why do you think the FBI is interested in your phone calls?
- D. I can assure you that your phone calls are not being monitored.
Correct Answer: A
Rationale: The correct response is to choose A: 'Let's talk about your feelings of being monitored.' This response shows empathy and encourages the client to express his feelings. Engaging the client in a discussion about his feelings can help address underlying fears without directly challenging the delusion. Choice B is incorrect because directly denying the delusion may lead to increased distrust or agitation in the client. Choice C may come across as confrontational, which can exacerbate the client's paranoia. Choice D offers a false sense of assurance and does not address the client's concerns effectively.
A client with schizophrenia is being treated with haloperidol (Haldol). The client reports feeling restless and unable to sit still. What should the nurse do first?
- A. Instruct the client to take deep breaths and relax.
- B. Assess the client for signs of akathisia.
- C. Encourage the client to engage in physical activity.
- D. Administer a PRN dose of lorazepam (Ativan).
Correct Answer: B
Rationale: Restlessness and inability to sit still are signs of akathisia, an extrapyramidal side effect of antipsychotic medications. The nurse should first assess the client for signs of akathisia by observing their movements and behavior. Assessing for akathisia is crucial to differentiate it from other conditions and to intervene appropriately. Instructing the client to relax or engage in physical activity may not address the underlying issue of akathisia. Administering lorazepam should not be the first action as it may mask the symptoms of akathisia temporarily without addressing the root cause.
An emergency department nurse is caring for an adult client who is a victim of family violence. Which priority instruction would be included in the discharge instructions?
- A. Information regarding shelters
- B. Instructions regarding calling the police
- C. Instructions regarding self-defense classes
- D. Explaining the importance of leaving the violent situation
Correct Answer: A
Rationale: The correct answer is A: Information regarding shelters. Providing information about shelters is crucial in cases of family violence as it ensures the client has a safe place to go after discharge, prioritizing their immediate safety. Option B, instructions regarding calling the police, may be necessary but ensuring a safe place to stay is more immediate. Option C, instructions regarding self-defense classes, may not be appropriate as the priority is to ensure the client's safety rather than teaching self-defense. Option D, explaining the importance of leaving the violent situation, is relevant but providing information on immediate shelter options is the priority.
Which statement about contemporary mental health nursing practice is accurate?
- A. There is one approved theoretical framework for psychiatric nursing practice.
- B. Psychiatric nursing has yet to be recognized as a core mental health discipline.
- C. Contemporary practice of psychiatric nursing is primarily focused on inpatient care.
- D. The psychiatric nursing client may be an individual, family, group, organization, or community.
Correct Answer: D
Rationale: The accurate statement about contemporary mental health nursing practice is that the psychiatric nursing client may be an individual, family, group, organization, or community. Mental health nursing extends beyond individual care to address the impact of psychiatric stressors on families, groups, and entire communities. Choices A, B, and C are incorrect: A is false as there are various theoretical frameworks used in psychiatric nursing, B is inaccurate as psychiatric nursing is a core discipline in mental health, and C is wrong as contemporary psychiatric nursing involves various settings beyond just inpatient care.